Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rocky Mountain Care - Evanston during CMS and state inspections, most recent first.
Unlabeled food was found in the walk-in refrigerator, and a cook was observed using soiled gloves while leaving the tray line, touching surfaces, handling bread, and continuing meal prep without removing the gloves. The dietary manager and dietitian stated open items in the refrigerator had to be labeled and dated, and staff were expected to remove gloves and perform hand hygiene when leaving the service line and before resuming meal service.
A resident with Alzheimer's Disease, depression, anxiety, and insomnia was severely cognitively impaired and unable to participate in BIMS scoring, yet the facility did not ensure regularly scheduled care plan meetings were planned or held. The resident representative said prior meetings only occurred after prompting, the record showed IDT care planning meetings in prior quarters, and the DON and Administrator confirmed no care plan meetings had been scheduled after the last documented meeting.
Failure to provide individualized 1:1 activities for a cognitively intact resident with dementia, depression, and blindness. The resident's MDS showed preferences for reading, music, animals, news, group activities, favorite activities, fresh air, and religious practices, and the care plan included weekly 1:1 visits. However, activity records showed no evidence that 1:1 activities were offered or refused, and the AD stated the facility did not have a set 1:1 activity or document when such visits were offered.
A resident with cognitive impairment and a history of falls, who required two-person assistance for transfers, was transferred by a CNA alone, contrary to the care plan. This resulted in the resident falling, sustaining a comminuted femur fracture above a knee prosthesis, and requiring significant pain management.
A resident with moderate cognitive impairment experienced verbal abuse from a CNA, who responded to the resident's expletives with a derogatory term. The incident caused emotional distress to the resident, who felt mocked and belittled. The CNA admitted to the behavior and was terminated. The resident, who typically used foul language, was notably affected, leading to the acceptance of counseling services.
The facility did not provide written transfer notices to two residents who were hospitalized, despite issuing bed hold notices. The administrator confirmed that while discharge notices included appeal rights and Ombudsman contact information, transfer notices for hospitalizations were not issued.
A resident with major depressive disorder, anxiety disorder, and PTSD remained in the facility beyond 120 days without a required level II PASARR being completed. The initial PASRR level I indicated the need for a level II determination if the stay was extended. The facility administrator confirmed the oversight.
The facility failed to inform two residents that signing a binding arbitration agreement was not a condition for admission or continued care. The agreements did not allow residents to decline the arbitration clause while accepting other terms. Despite claims that no such agreements were signed, records showed otherwise, and the facility's lawyer acknowledged issues with older agreements.
Unlabeled Food Storage and Improper Glove Use During Meal Preparation
Penalty
Summary
Food was not stored and prepared in accordance with professional standards in the kitchen. On 4/14/26 at 6:24 AM, surveyors observed a red tub containing a thick yellow substance in the walk-in refrigerator. The bowl was not labeled or dated, and the substance appeared to have portions removed. The dietary manager and dietitian later identified the substance as potato salad and stated they were not sure when it was made. They also stated that items in the walk-in refrigerator were available for resident consumption and that all open items had to be labeled and dated. On 4/15/26 at 12:09 PM, cook #1 was observed plating meals on the tray line while wearing gloves. Without removing the gloves, the cook left the line, touched the three-compartment sink, placed a hand on top of a table, obtained a bag of bread, and returned to the tray line. The cook then opened the bread bag and used the same soiled gloves to remove two slices of bread, placed an enchilada on the bread, and gave the tray to staff in the dining room for a resident. The cook returned to the service line and continued preparing meal trays without removing the soiled gloves. The dietary manager and dietitian stated they expected staff to remove gloves and perform hand hygiene when leaving the service line and before resuming meal service.
Failure to Schedule Regular Care Plan Meetings
Penalty
Summary
The facility failed to ensure resident #3 was notified in advance and included in regularly scheduled care plan meetings for development and implementation of the person-centered plan of care. The quarterly MDS showed the resident was unable to participate in BIMS scoring because the resident was rarely or never understood and was severely impaired in daily decision making. The resident had diagnoses of Alzheimer's Disease, depression, anxiety, and insomnia. The resident representative stated the resident had two care plan meetings in the last year, but those meetings were prompted by the representative. The medical record showed interdisciplinary team care planning meetings with the resident representative invited in April 2025, July 2025, and October 2025, but there was no evidence of a care plan meeting planned or held in 2026. The DON confirmed the resident had no IDT meetings for care plan updating since October 2025 and none were scheduled, and the Administrator stated care plans had been revised quarterly with no scheduled meetings.
Failure to Provide Individualized 1:1 Activities
Penalty
Summary
The facility failed to ensure individual activities of preference were provided for one resident who was cognitively intact with a BIMS score of 15 out of 15 and diagnoses including non-Alzheimer's dementia, depression, and blindness in both eyes. The resident's MDS indicated that it was very important to have books, newspapers, and magazines to read, listen to music, be around animals, keep up with the news, do things with groups of people, do favorite activities, get fresh air when the weather was good, and participate in religious services or practices. The Recreation Therapy care plan, last revised on 12/31/26, included an intervention to provide a 1:1 visit once weekly. Observation showed the resident in the room independently listening to an audio book. The resident stated s/he did not participate in many activities because of blindness and did not have many visitors, and said staff did not come to the room for visits. Review of activity participation records for the two-month period showed no evidence the resident was offered 1:1 activities or refused them. The activity director stated the resident's family provided many activities, the resident listened to audio entertainment, and the facility only did 1:1 activities when reading mail to the resident; she also stated the facility did not have a set 1:1 activity with the resident and did not document when 1:1 activities were offered, and the facility did not have a policy related to 1:1 activities.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, Alzheimer's disease, and bipolar disorder, who required substantial to maximal assistance with all mobility activities of daily living (ADLs), was not provided a safe transfer as outlined in their care plan. The care plan specified that two staff members were required to assist with transfers due to the resident's fall history and high level of assistance needed. Despite this, a certified nursing assistant (CNA) attempted to transfer the resident alone, resulting in the resident losing balance, falling, and hitting their head. Initial nursing assessment did not reveal injury or pain, and the resident resumed normal activities. Subsequently, the resident began to complain of severe knee pain and was diagnosed with a comminuted fracture above the left knee prosthesis, which was inoperable. The resident was placed on non-weight bearing status and required increased pain management. The facility's investigation confirmed that the CNA did not follow the care plan, leading to the resident's fall and injury.
Verbal Abuse Incident Involving Resident and CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, resulting in actual psychosocial harm. The incident involved a resident with moderate cognitive impairment and a history of cerebrovascular accident, hemiplegia or hemiparesis, and depression. During an incident, the resident used expletives towards a CNA, who responded by calling the resident a derogatory term. The resident reported feeling mocked and belittled by the CNA, which led to emotional distress. The resident's representative confirmed the resident's feelings of embarrassment and belittlement, and the resident was described as being stunned after the incident. The investigation revealed that the CNA admitted to using the derogatory term and was subsequently terminated. The resident, who often used foul language, was notably affected by this incident, as evidenced by their acceptance of counseling services afterward. The facility's administrator confirmed the resident's unusual emotional response and the initiation of counseling services. The facility's policy on abuse, neglect, and exploitation was reviewed, highlighting the requirement to prohibit and prevent such incidents.
Failure to Provide Written Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written notice of transfer to the resident and/or their representative for two residents who were hospitalized. Resident #3 was admitted to the hospital on March 30, 2024, and returned to the facility on a later date. Although the resident received a bed hold notice, there was no evidence of a written transfer notice being issued. Similarly, resident #21 was hospitalized on July 14, 2024, and returned to the facility on a later date, but also did not receive a written transfer notice, despite receiving a bed hold notice. During interviews, the facility administrator acknowledged that while written notices containing appeal rights and Ombudsman contact information were issued for discharges, they did not issue written transfer notices for hospital transfers.
Failure to Complete Level II PASARR for Resident
Penalty
Summary
The facility failed to complete a required level II PASARR for a resident who was admitted with diagnoses of major depressive disorder, anxiety disorder, and PTSD. The initial PASRR level I screening indicated that the resident had a major mental illness and was categorically appropriate for convalescent care after an acute hospital stay, not to exceed 120 days. The screening also noted that an individualized level II determination would be required on the 120th day if the resident's stay was to be extended. Despite the resident remaining in the facility beyond 120 days, there was no evidence in the medical record that the level II PASARR was completed. The facility administrator acknowledged that the level II PASARR was not conducted as required.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement explicitly stated that residents or their representatives were not required to sign the agreement as a condition of admission or to continue receiving care. This deficiency was identified for two residents who signed admission agreements that included a binding arbitration clause. The agreements did not provide an option for the residents to decline the arbitration agreement while agreeing to the rest of the admission terms. Despite the administrator's statement that no residents had signed binding arbitration agreements, medical record reviews revealed otherwise. The facility's lawyer acknowledged that older admission agreements were problematic, although the facility had revised their admission agreements in 2023 to comply with regulations related to arbitration.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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